Can LDL-C Be Too Low?

The question of whether low-density lipoprotein (LDL) levels can be too low often arises in clinical practice, according to the panelists, especially when patients with very low LDL express concern. Some worry that such low levels could negatively affect their overall health, particularly in relation to essential functions like cholesterol production. However, the data strongly support the idea that lower LDL is generally better for preventing cardiovascular events without significant risk of harm. For instance, studies have shown that even patients with naturally low LDL, such as those with familial hypercholesterolemia or PCSK9 mutations, tend to have longer life spans without cognitive impairments.

The misconception that low LDL might lead to cognitive issues, often referred to as brain fog, is not supported by clinical data. Research from studies like FOURIER and EBBINGHAUS, which examined patients with extremely low LDL, revealed no significant cognitive differences compared to those with higher levels. Cognitive complaints in these cases were rare and not linked to cholesterol levels. This is reassuring for patients concerned about adverse effects from aggressive lipid-lowering therapies.

In practice, patient concerns are often addressed by explaining the science behind LDL reduction and emphasizing the benefits in terms of reducing the risk of heart attacks, strokes, and mortality. The key message is that lowering LDL is not just about reducing cholesterol but about minimizing long-term cardiovascular risk. Many patients, especially those who initially resist statins or other lipid-lowering treatments, respond well when the conversation shifts from cholesterol to overall health outcomes. Educating patients on the importance of LDL reduction in preventing serious events helps in overcoming resistance to necessary treatments.